Czech Republic

Country

• Approximately 10,5 million inhabitants
• Expenditure on health 2009: EUR ca 11,5 billion (7,9% of the gross domestic product)
• The costs caused directly by mental and behavioral disorders 2009: amounted to 3-4% of expenditure on health (ca EUR 0.5 billion)

Psychotherapy in the health care system

• Psychotherapeutic healthcare is financed for about 95 percent of the population by the insurance systems, covering the full range of inpatient care (hospitals, clinics), semi-inpatient care (day clinics) and outpatient care (surgeries, hospital outpatient units). Everyone not covered by the insurance may opt for private offers. Everyone who wish other methods that are not covered by the insurance, or who wish up-standard care (e.g. treatment by concrete therapist, treatment as quickly as possible etc.) can step out of insurance system and seek centre where he/she have to pay in cash.
• Not all psychotherapists have contracts with all insurance companies. 
• Psychotherapy is defined as a form of treatment for mental and behavioral disorders classified by the International Classification of Diseases.
• For outpatients, diverse forms of psychotherapy are covered by the insurance system. There are no restrictions in the field. The form of treatment depends only on the contract with the clinician. CBT, eclectic, integrative, psychodynamic, gestalt psychotherapy and family therapy are the most widespread modalities.
• For inpatients there are no restrictions on psychotherapeutic approaches as well. Traditionally the group psychotherapy and different forms of art therapy are very often adopted in treatment in the psychiatry hospitals.
• Outpatient psychotherapy: patients have free access to psychotherapy. Indications are very similar to those mentioned by Prof. Richter. Social disturbances, stress and personal crisis or marital crisis are often mentioned indicators by subjects. Psychotherapy may also be indicated with somatic diseases, if psychological factors are pathogenic or impair health. Patients can choose their therapist from a list of licensed psychotherapists. In fact, choosing from Internet’s advertisements has rapidly increased. Limitations are set by session quotas by insurance companies, but only indirectly (e.g. per day, per month or per approach per day; e.g. family therapy sessions are limited to 4 per 30 minute per day). Differences between insurance companies and also between regions do exist. It seems that the politics of insurance companies differs substantially and in principle have a high power to create solutions and penalize both individual therapists and health care centres. According to the psychotherapists in practice the situation is very confusing and stressful. Group therapy is also financed in outpatient psychotherapeutic care.
• Psychotherapy is paid for after approval by the insurance company’s medical service.
• No general “Guidelines for Psychotherapy” exist in the country, but standards exist for individual, group and family therapy.
• Inpatient care for persons with mental disorder is offered by psychiatric and psychosomatic hospitals and rehabilitation centres. There are no restrictions regarding the use of different psychotherapeutic approaches in clinics. The average duration of treatment is 6 weeks in psychiatric and up to 8 weeks in psychosomatic hospitals.

Psychotherapeutic Professionals

• However, the profession 'psychotherapist' is not regulated by law. Only qualification in psychology and psychiatry and post-graduated specialization for psychotherapy is regulated. It includes a minimum of 5 years of practice in health care institution, the work under supervision and systematic training in an approved psychotherapeutic approach. In the Czech Republic approximately 40 trainings have been approved since 90’s. There are acknowledged by Czech Psychotherapeutic Society, by Czech Psychiatry Society and by Association of Clinical Psychologists.
• Some of the training institutes offer free access to their programme. Some of them insist that only psychologists, medical doctors and nurses can be trained. There is no difference between psychotherapy with adults and Child and youth psychotherapy. The main acknowledged modalities are: psychodynamic, psychoanalytic psychotherapy, CBT, integrative, gestalt, psychosomatic, family, group, systemic and person-centred therapy. Some of new modalities have been acknowledged just recently, e.g. biosynthesis. Some minority schools are acknowledged as well, like analytical psychotherapy according C. G. Jung.
• In 2008, 660 psychiatrists and 80 psychologists were working in outpatient clinics and surgeries; and 550 psychiatrists and 130 psychologists (and 2940 nurses) were working in psychiatry hospitals. Not all of them are trained in psychotherapy. Some hundreds of psychologist were offering their care also in cash.

Psychotherapy for Depression

• In outpatient care depression is second widespread diagnosis (after group of neuroses); number of depression has increased in years 2003–2008. In psychiatry hospitals depressive patients are the third group of patients (after neuroses and schizophrenia). Combination of individual and group therapy, as well as specialized treatment programs are recommended in psychiatry hospitals. The wide used modalities are CBT and psychodynamic approach. In cases of moderate depression, psychotherapy is highly recommended; in cases of severe depression a combination of pharmacology and psychotherapy is recommended; approximately 20-30% of patients are treated without psychotherapy.

Desirable Changes to Health Policy

• The density of psychotherapeutic care differs widely across Czech Republic. The best situation is in big cities like Prague, or Brno. In psychiatry hospitals there are 0,5 psychiatrist for 10 000 inhabitants. The similar difference between urban area and rural area does exist. However the reform in psychotherapeutic care is not planned at the time.

Additional Information

• In Czech Republic, doesn’t require a compulsory membership for psychotherapists. The majority of psychological psychotherapists working in clinical practice are member of Czech Psychotherapeutic Society of Czech Medical Society (CPS). The board of CPS provides such activities like acknowledgement and supervision of trainings standards, or negotiations with insurance companies, or Ministry of Health.

References
Faltus, F., Janečková, E., Anders, M. (2010). Vývoj psychiatrické péče v ČR. Vývoj sítě ambulantních a lůžkových psychiatrických zařízení. Čes a slov psychiatrie 106(6): 366-371
Půlpánová, P. (2009). Psychoterapie deprese v České republice. Brno: FSS MU. Nepublikovaná diplomová práce.

Author
Ass. Prof. Dr. Zbyněk Vybíral, Psychologist and Psychotherapist, Department of Psychology, Faculty of Social Sciences, Masaryk University (Czech Republic)

The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".

You can download the paper here.